Community Acquired Acute Gastrointestinal Infection ( including Food Poisoning ) in Adults Seen in Accident and Emergency and/or Requiring Hospital Admission - Guideline for the Management of

Publication: 01/01/2008  
Last review: 21/08/2017  
Next review: 01/08/2020  
Clinical Guideline
CURRENT 
ID: 1211 
Approved By: Improving Antimicrobial Prescribing Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2017  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Guideline for the Management of Community Acquired Acute Gastrointestinal Infection (including Food Poisoning) in Adults Seen in Accident and Emergency and/or Requiring Hospital Admission

Summary
Community Acquired Acute Gastrointestinal Infection ( including Food Poisoning ) in Adults Seen in Accident and Emergency and/or Requiring Hospital Admission

Background and history:

  • Acute gastroenteritis is an illness of <14 days duration characterized by the presence of diarrhoea (3 or more loose stools per day or bloody stools).
  • Accompanying symptoms may include abdominal pain/cramps, nausea, vomiting and fever.
  • Causes included a wide range of bacterial (e.g. Campylobacter spp., Salmonella spp., certain strains of Escherichia coli), viral and protozoal pathogens.
  • The history should identify pre-existing medical conditions that increase the risk of an adverse outcome (e.g. immunosupression).
  • It is also important to ascertain the potential source of the infection by asking about travel history, contact with a similar illness affecting others and possible food sources.
  • C.difficile infection should be considered in patients where risk factors are present (click here).
  • As the symptoms/signs of gastroenteritis are nonspecific, alternative diagnoses should also be considered.
  • Certain Shigella and E.coli infections (e.g. E.coli O157) can be complicated by Haemolytic-Uraemic syndrome (HUS). The clinical features are non-specific (unless Thrombotic Thrombocytopenic Purpura (TTP) is present) and can follow resolution of gastroenteritis.

Examination:

  • A full physical examination must include assessment of the patient’s vital signs, features of dehydration and evidence of peritonism.

Basic investigations:

  • Send blood for FBC, U&E, LFT and CRP in patients requiring hospital admission.
  • Check other electrolytes if indicated (e.g. sepsis).
  • Take blood cultures if the patient has features of sepsis or if enteric fever (typhoid or paratyphoid) is suspected.
  • A blood film, urinalysis and haemolysis screen will be required if HUS is suspected.
  • Consider an abdominal radiograph if there is abdominal pain/distension. An erect chest radiograph should be performed if there is evidence of peritonism (C).

Stool sampling:

  • Send a stool sample for bacterial cultures (MC&S) in all patients. For patients who are being discharged (for example from A&E or admissions units), supply a faeces collection container and advise them to deliver a sample to their GP at the earliest opportunity.
  • Stool sampling for enteric virus PCR should be performed in patients who are hospitalised, the immunocompromised, and when cases may be part of an outbreak.
  • Request toxin testing if the patient has any risk factors for Clostridium difficile infection (CDI; see history section).
  • If the patient is immunocompromised, there is a history of foreign travel, or symptoms have been present for more than 2 weeks then 3 stool samples may be sent for ova, cyst and parasite (OCP) examination.
  • Include pertinent clinical details on the request form, e.g. travel history/possible food source. Note that in the absence of clinical details the sample will not be processed.

Non-Antimicrobial Management:

  • Ensure adequate rehydration using either oral fluids if tolerated, or intravenous fluids.
  • Do not use anti-diarrhoeals as they may worsen acute gastroenteritis and its complications.

Empirical (initial) antimicrobial treatment:

  • Arrange admission to hospital if:
    • the patient is vomiting and unable to retain oral fluids
    • there are features of sepsis, dehydration, or shock
  • The majority of patients with acute gastroenteritis DO NOT require antimicrobial treatment as the illness will be self-limiting and without sequelae.
  • Patients with acute gastroenteritis who present with RED FLAG features of sepsis/shock require prompt antimicrobial treatment, unless there is evidence of HUS (in which case discuss case with Microbiology/Infectious Diseases). For definition of sepsis click here.
  • Treatment is as per complicated intra-abdominal infection guideline: click here
  • * If Campylobacter infection strongly suspected, add IV Clarithromycin electronic Medicines Compendium information on Clarithromycin  500mg BD
  • N.B. doses assume normal renal function. Please check dose with pharmacist if patient has renal impairment
  • Empirical therapy should also be started in those who are immune-compromised.
  • If these patients are well enough to tolerate oral antibiotics, start Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin
  • Note: as symptoms/signs of acute gastroenteritis can occur in cases of sepsis caused by infection at other sites (e.g. pneumonia), consider if the empirical antibiotic choices given in the sepsis guideline may be most appropriate (click here).
  • Any patient with a history of recent foreign travel suggesting possible enteric fever (typhoid or paratyphoid), or who is allergic to these empirical antimicrobial agents should be discussed with Microbiology/Infectious Diseases.

Table 1: summary of pathogen-specific antimicrobial treatment:

  • Remember, antibiotic therapy is NOT required in adults with uncomplicated gastroenteritis.
  • If antibiotic therapy is started it must reviewed in light of the sensitivity results for the organism.

Pathogen

Suggested antibiotic (dose*, route** and duration†)

Alternative antibiotic (e.g. if allergic to first line agent)

Campylobacter

Clarithromycin electronic Medicines Compendium information on Clarithromycin 500mg 12-h orally for 5 days

Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin

Clostridium difficile

See separate LTHT guideline

N/A

E.coli O157 (and other verotoxin producing strains)

None (discuss with ID/Micro)

None

Salmonella (except enteric fever)

Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin
(if history of travel to SE Asia/Indian subcontinent or possible/confirmed Salmonella Typhi/Paratyphi discuss URGENTLY with ID)

Discuss with Microbiology/ID

Shigella

Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin
(NB No antibiotics recommended if associated HUS – discuss with ID/Micro)

Azithromycin electronic Medicines Compendium information on Azithromycin 500mg 12-h orally for 3 days

Yersinia enterocolitica

Treatment not usually indicated, but contact ID/Microbiology if severe or patient has risk factors (see full guideline)

 

Aeromonas

Treatment not usually recommended (see full guideline)

 

Cryptosporidium

None (unless severe/immunocompromised – discuss with ID/Micro)

N/A

Enteric viruses (e.g. Norovirus)

None

N/A

* Doses assume normal renal function. If renal impairment present consult pharmacy.
** Certain patients, e.g. immunocompromised, may need longer duration. Discuss with Microbiology/Infectious Diseases.


Referral criteria for specialist input (Infectious Diseases/Microbiology):

  • Cases where empirical therapy is indicated but the patient is allergic to first line agents.
  • Cases associated with overseas travel, especially if enteric fever (typhoid or paratyphoid) is possible.
  • Patients who have recently received a course of a first line antibiotic for any reason.
  • Any case associated with HUS +/- TTP.
  • HUS/TTP: involve a renal physician if HUS and also a neurologist if TTP.

Referral to Public Health England:

  • Doctors who suspect they are managing a case(s) of suspected food poisoning should notify the West Yorkshire Health Protection Team by telephone (tel: 0113 3860300 from 9am to 5pm Monday-Friday, or the Out-of-hours advice service on 0114 304 9843 at other times) or by the submission of a notification form.
  • Cases of HUS, infectious bloody diarrhoea, enteric fever (typhoid or paratyphoid) and food poisoning that is part of a cluster/outbreak should also be urgently notified.
  • If a case involves a food handler this should also prompt urgent notification.

Back to top

Background

Globally there are estimated to be two billion cases of diarrhoeal disease per year, and it is the second leading cause of morbidity and mortality in children under 51. Whilst more common in the developing world, acute gastroenteritis is still a significant problem in the UK. In 2013, there were 66,575 reported cases of Campylobacter, along with 8,459 cases of non-typhoidal Salmonella25. Overseas travel is a significant risk factor 4, but many cases are not associated with travel.

In healthy adults acute gastroenteritis is usually mild and self-limiting, but it can cause severe illness or be associated with complications requiring hospitalisation, especially in those with comorbid conditions. In addition, a large population-based study in the USA showed a mortality rate of 0.5% for confirmed food-borne bacterial gastroenteritis 5.

Table 2: Common causes of acute gastroenteritis:

Bacterial

Viral

Protozoal

Campylobacter spp. *

Norovirus

Cryptosporidium spp.

E.coli (including VTEC strains, e.g. O157, O117 *)

Sapovirus

Giardia intestinalis/lamblia

Shigella spp.*

Rotavirus

Entamoeba histolytica *

Salmonella spp.*

Adenovirus

Cyclospora cayetanensis

Clostridium difficile *

 

 

Vibrio spp.

 

 

Yersinia enterocolitica

 

 

Listeria monocytogenes

 

 

Aeromonas sp.

 

 

Plesiomonas shigelloides

 

 

* = organisms associated with bloody stools (dysentery).

Back to top

Clinical Diagnosis

History:
Diarrhoea is defined as the passage of 3 or more loose or watery stools in 24h, or the passage of one or more bloody stools 6. Conventionally, acute diarrhoea describes an illness that has lasted less than 14 days. Accompanying symptoms may include nausea, vomiting, fever, abdominal cramps/pain and tenesmus. Of note, no symptom or combination of symptoms is sensitive or specific enough to aid in the diagnosis of any particular pathogen.

When taking a history from a patient with gastroenteritis it is important to cover the following elements 7:

  1. Nature of onset (abrupt or gradual)
  2. Duration of symptoms
  3. Frequency of bowel movements (per 24h) and relative quantity of stool produced
  4. Stool characteristics
  5. Presence of dysenteric symptoms (blood or mucus in stool, fever, tenesmus, abdominal pain)
  6. Symptoms of dehydration
  7. Associated symptoms and their frequency/intensity (e.g. nausea, vomiting, abdominal pain/cramps)

It is important to identify patients who are immune-compromised as they are at increased risk of an adverse outcome, and may benefit from treatment 8.

A review of the patient’s medication may identify drugs whose absorption can be affected by severe gastroenteritis (e.g. warfarin) and those that can exacerbate dehydration/renal failure, which may therefore need omitting temporarily (e.g. diuretics, angiotensin-converting enzyme inhibitors).

An attempt should also be made to try and identify the potential source of the infection. It is important to ask about 9:

  1. Recent contact with someone with acute diarrhoea and/or vomiting
  2. Exposure to a known/potential source of enteric infection (e.g. consumption of unsafe food/water, animal contact)
  3. Recent foreign travel
  4. Factors that increase the risk of Clostridium difficile infection (CDI), e.g.:
    1. Recent (< 8 weeks) antibiotics
    2. Recent (<8 weeks) hospitalization
    3. Living in a care home

It is important to ascertain a patient’s occupation as it may influence the public health advice they require, e.g. for food-handlers or health/social care workers.

Examination:

A full physical examination should be performed and must include an assessment of the following features:

  1. General status of the patient, especially vital signs (calculate a NEWS score; see appendix in sepsis guideline).
  2. Signs of dehydration
  3. Evidence of peritonism (which may suggest an alternative diagnosis).

NOTE:

The symptoms and sings of acute gastroenteritis are not specific 6. They may be a presenting feature of numerous other conditions. Therefore, do not forget to consider alternative diagnoses as appropriate to the clinical picture. These may include:

  1. Acute surgical pathology (e.g. peritonitis, diverticulitis)
  2. Sepsis from another source
  3. Urinary tract pathology (including infection)
  4. Inflammatory bowel disease
  5. Systemic or other illnesses (e.g. diabetic ketoacidosis, myocardial infarction).

Haemolytic-uraemic syndrome (HUS):
Features of HUS are non-specific. The diarrhoea caused by verotoxin producing organisms (e.g. E.coli O157) is typically bloody and associated with severe abdominal cramps but no fever. HUS may follow resolution of the diarrhoea at approximately 1-2 weeks. Patients may complain of fever, fatigue, malaise and arthralgias. Urine output may be reduced and the urine dark in colour or with evidence of haematuria. In adults features of Thrombotic Thrombocytopaenic Purpura (TTP) can occur, such as headaches, seizures and focal neurological signs. There may be a petechial rash.

Enteric fever:
Enteric fever is caused by Salmonella Typhi and Paratyphi. Most cases in Leeds are associated with travel to the Indian Subcontinent, but it can be seen in travellers returning from South America, Africa and South East Asia. The patient is invariably febrile or has a history of fever. Other features are variable/non-specific and may include: headache, dry cough, malaise, abdominal pain, diarrhoea (usually mild) and constipation.

Back to top

Investigation

Basic investigations:
All adult patients with gastroenteritis who are unwell enough to require hospital admission should have the following investigations sent: FBC, U&E, LFT, CRP (Evidence level D). It may also be necessary to check the levels of other electrolytes, e.g. magnesium.

If HUS is suspected then request a blood film, perform urinalysis and a haemolysis screen (Evidence level D).

Take blood cultures if the patient has features of sepsis or if enteric fever (typhoid or paratyphoid) is suspected. See LTHT guideline for blood culture sampling

Consider an abdominal radiograph if there is abdominal pain/distension. An erect chest radiograph should be performed if there is evidence of peritonism (Evidence level C).

Stool sampling:
A stool sample for bacterial culture (MC&S) should be sent from all patients with suspected community-acquired acute gastroenteritis (Evidence level C). This will be tested for the presence of Salmonella, Shigella, Campylobacter, and E.coli O157. In addition, samples received from patients with a history of travel to certain countries or seafood ingestion will be cultured for Vibrio species. It is therefore important to ensure the request form is completed correctly, including all relevant details. Note that in the absence of clinical details the sample will be rejected by the laboratory.

Given the high prevalence of enteric viruses in a recent UK survey of the causes of community-acquired gastroenteritis 10 stool (or vomit) samples should be sent for enteric virus PCR in the following groups: patients who are admitted to hospital, the immunecompromised and cases that may be part of an outbreak (Evidence level D).

Testing for Clostridium difficile toxin is routinely undertaken in patients over 65 years old but should be requested in any patient with risk factors for CDI (see history section; Evidence level C).

If there is a history of recent travel, the patient is immunocompromised, or symptoms have been present for more than 2 weeks, three stool samples should be sent for ova, cysts and parasites (OCP; Evidence level C).

Consider investigations relevant to other conditions in the differential diagnosis, as required.

Back to top

Treatment
Non-Antimicrobial Treatment

Rehydration:
Most adults with acute gastroenteritis who can tolerate oral fluids can be managed with advice to increase fluid intake and take salt in foods such as crackers and soups (Evidence level C) 11. Guidelines frequently recommend the use of Oral Rehydration Solution 6-8,11 using the reduced-osmolality formula advocated by the World Health Organisation (Evidence level A)12. This can be particularly useful in older patients or those with comorbidities to help correct dehydration and replace electrolytes. Those who are unable to tolerate oral fluids or who have severe dehydration will require intravenous fluids.

Anti-diarrhoeals (e.g. loperamide, co-phenotrope and codeine):
These agents should be avoided (Evidence level A) as they may enhance tissue invasion by some organisms and may delay clearance from the bowel 6. They have specifically been shown to prolong fever in shigellosis 13 and to increase the risk of HUS in children with E.coli O157 infection 14.

Source isolation:
All patients admitted with suspected acute gastroenteritis require source isolation (see LTHT infection control guideline).

Back to top

Empirical Antimicrobial Treatment

A number of randomized controlled trials have compared antibiotic therapy with placebo in the management of community-acquired acute gastroenteritis 15-17. Whilst they have shown a reduction in the duration of symptoms of between 1-2 days this has to be balanced against the potential negative consequences of empiric therapy in an illness that is self-limiting and without long-term consequences in most adults. Antimicrobials can be associated with the following unwanted effects: increased excretion of salmonellae 18, adverse reactions, harmful eradication of normal bowel flora (which may predispose to CDI), the induction of verotoxin production (increasing the risk of HUS) 19 and the emergence of antibiotic-resistant pathogens 15, 17. For these reasons the use of antimicrobial therapy for the empirical treatment of acute gastoenteritis is NOT recommended in most patients (Evidence level C). This policy is in line with the recommendation of published guidelines 7-9, 12.

However, if a patient has RED FLAG features of sepsis/shock, empirical antibiotics should be started promptly. For information on the features of sepsis click here.

Antimicrobials should also be started in patients who are immunocompromised.

They can be considered in those who have severe acute symptoms (even if they do not have evidence of sepsis/shock).

Despite rising rates of quinolone resistance in Salmonella and Campylobacter species, published guidelines still recommend one of these agents, usually Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin6-8,11 (Evidence level C). This is, however, no longer the case for Salmonella Typhi/Paratyphi (the causative agents of enteric fever). Cases of suspected enteric fever should be discussed URGENTLY with Infectious Diseases. If the patient has a life-threatening infection or is immunocompromised several authors advise adding a macrolide to treat quinolone-resistant Campylobacter species 11, 12 (Evidence level C).

Summary of empirical antibiotic recommendations for severe acute gastroenteritis (note antibiotics are NOT recommended in the majority of cases, ONLY if patients fulfil the criteria outlined above):

  • Antibiotic recommendations concur with those of the Complicated intra-abdominal infection guideline: click here
  • * If Campylobacter infection strongly suspected, add IV Clarithromycin electronic Medicines Compendium information on Clarithromycin  500mg BD
  • Any history of recent foreign travel/suspected enteric fever (typhoid or paratyphoid): discuss case URGENTLY with Infectious Diseases
  • If C.difficile infection is suspected clinically then see LTHT guideline.

N.B. If there is clinical/laboratory evidence of HUS antibiotics should be avoided as they may worsen the condition. These cases should be discussed with Microbiology/Infectious Diseases.

It is important to remember that symptoms of gastroenteritis can occur in sepsis due to other causes. If the clinical presentation suggests that an alternative aetiology, other than acute gastroenteritis, is more likely, then refer to the LTHT sepsis guideline for empirical antibiotic advice.

N.B. All doses assume normal renal function. If patient has renal impairment consult a pharmacist for dosing advice.

Back to top

Directed Antimicrobial Treatment (when microbiology results are known)

Note that the majority of patients without sepsis will not require treatment, even when the causative pathogen is identified. See organism-specific notes below for full recommendations.

All cases will still require notification to the HPU (see below).

Campylobacter:
Antimicrobial therapy is not normally required for Campylobacter enteritis and may select for resistant organisms 15, 17. Those with severe or prolonged (>1 week) infection, and those at increased risk of complications (as defined above but including pregnant women) 11 should be considered for treatment. First line therapy is with a macrolide (e.g. Clarithromycin electronic Medicines Compendium information on Clarithromycin or Azithromycin electronic Medicines Compendium information on Azithromycin) for 5 days 6, 9. The alternative is Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin7. Collective data (2010-2015) from Leeds microbiology laboratory shows a 31% non-susceptible rate in local Campylobacter isolates to Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin, with only 8% (children) and 5% (adults) non-susceptible rates to macrolides.  In addition quinolones are contraindicated in pregnancy and breastfeeding. If an antibiotic is started it must be reviewed in the light of sensitivity results.

Salmonella (not including enteric fever):
A Cochrane meta-analysis found no evidence of benefit in using antibiotics to treat non-severe Salmonella gastroenteritis in otherwise healthy adults 18. Antibiotic use was associated with an increased rate of side effects and tended to prolong Salmonella excretion. Therefore most patients do not require treatment. However, antibiotics should be considered in those at risk of severe or disseminated disease/metastatic seeding - this includes patients in the groups identified above (see history section) and those with sickle cell and other haemoglobinopathies, artificial joints, , vascular grafts, and valvular heart disease11. First line treatment is Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin for 5 days. High rates of quinolone resistance in Salmonellae in other areas of the world, such as the Indian sub-continent and South East Asia, mean that any cases associated with travel should be discussed with Microbiology or Infectious Diseases.

Enteric fever:
If enteric fever (caused by Salmonella Typhi or Paratyphi) is expected clinically or confirmed from blood culture then refer the patient URGENTLY to Infectious Diseases.

Shigella:
Shigella enteritis in the UK is most commonly caused by S. sonnei 22 which generally produces a mild, self-limited illness that is unlikely to require treatment. However, other species frequently produce dysentery and may be associated with other complications, including HUS. Evidence supports the use of antibiotics in treating these species, both to reduce the duration of diarrhoea and to try and prevent spread of the infection 23 (unless there is accompanying HUS). First line treatment is with Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin for 5 days, with Azithromycin electronic Medicines Compendium information on Azithromycin as an alternative 6. Sensitivity to the agent used must be confirmed by laboratory testing.

E.coli O157 (and other verotoxin producing strains):
Management is supportive only. Antibiotics are not recommended as they do not improve the course of the disease and may increase the risk of HUS 20 through inducing verotoxin production 21, though this effect was not confirmed in a meta-analysis 22. Patients require clinical and laboratory monitoring for the development of HUS as these cases may ultimately require dialysis. Therefore if HUS is present refer to Nephrology (Evidence level D). If there are feature of TTP refer to Neurology.  All VTECs should be reported to Health Protection Teams who will carry out public health follow-up. 

C.difficile:
If CDI is suspected (for example if there is a history of recent antibiotic use or hospitalisation) please refer to the relevant LTHT guideline for management advice.

Aeromonas:
Whilst this organism may be isolated from the stool of patients with gastroenteritis, its role as a pathogen is unclear. Therefore treatment is not normally recommended. However, if it is the only organism isolated from the stool of a patient with severe gastroenteritis in whom treatment is being considered, the case can be discussed with either Microbiology or Infectious Diseases.

Yersinia enterocolitica:
Yersiniosis is most commonly a self-limiting gastroenteritis. The diarrhoea may be bloody. In children it can also cause mesenteric adenitis, which often mimics acute appendicitis. Patients with the following comorbidities are at risk of severe/bacteraemic disease: immunosuppression, diabetes, cirrhosis, iron-overload states (e.g. patients with haematological disorders requiring frequent blood transfusions, patients on desferrioxamine therapy for any reason). These patients, and any others with sepsis, must be discussed with either Microbiology or Infectious Diseases, as treatment is indicated. Cases of mild-moderate disease in those without risk factors do not require antimicrobials.

Cryptosporidium:
In immunocompetent adults, cryptosporidium usually causes a self-limited diarrhoeal illness 24. However in the immunocompromised, including those with advanced HIV, it can cause chronic diarrhoea associated with malabsorption. These patients should be discussed with Microbiology or Infectious Diseases as treatment may be indicated.

Enteric viruses:
Enteric viruses, e.g. norovirus and sapovirus, produce an acute, self-limited gastroenteritis for which care is supportive. They are easily transmitted. For this reason prompt and effective infection control, according to LTHT guidelines, is one of the most important interventions.

Others:
Of other pathogens, e.g. Vibrio, Entamoeba, Giardia, or Cyclospora spp. are identified in the stool their specific management should be discussed with Microbiology or Infectious Diseases.

Table 3: Summary table of recommended antibiotics against specific enteric pathogens:

Pathogen

Suggested antibiotic (dose*, route** and duration†)

Alternative antibiotic (e.g. if allergic to first line agent)

Campylobacter

Clarithromycin electronic Medicines Compendium information on Clarithromycin 500mg 12-h orally for 5 days

Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 500mg 12-h orally for 5 days

Clostridium difficile

See separate LTHT guideline

N/A

E.coli O157 (and other verotoxin producing strains)

None (discuss with ID/Micro)

None

Salmonella (except enteric fever)

Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 500mg 12-h orally for 5 days
(if history of travel to SE Asia/Indian subcontinent or possible/confirmed Salmonella Typhi/Paratyphi, discuss URGENTLY with ID)

Discuss with Microbiology/ID

Shigella

Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 500mg 12-h orally for 5 days
(NB No antibiotics recommended if associated HUS – discuss with ID/Micro)

Azithromycin electronic Medicines Compendium information on Azithromycin  500mg 24-h orally for 3 days

Yersinia enterocolitica

Treatment not usually indicated, but contact ID/Microbiology if severe or patient has risk factors

 

Aeromonas

Treatment not usually recommended

 

Cryptosporidium

None (unless severe/immunocompromised – discuss with ID/Micro)

N/A

Enteric viruses (e.g. Norovirus)

None

N/A

* Doses assume normal renal function. If renal impairment present consult pharmacy.
** All recommendations are for oral therapy. If this is not appropriate give IV treatment as follows:

Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin (electronic Medicines Compendium information on) Ciprofloxacin 400mg 12-h

Switch oral to IV Clarithromycin electronic Medicines Compendium information on Clarithromycin (electronic Medicines Compendium information on) Clarithromycin electronic Medicines Compendium information on Clarithromycin 500mg 12-h

†Certain patients, e.g. immunocompromised, may need longer duration. Discuss with Microbiology/Infectious Diseases.

Notification of cases to Public Health England:

Cases of food poisoning, HUS, infectious bloody diarrhoea, and enteric fever (typhoid or paratyphoid) should be notified urgently (within 24 hours) to the West Yorkshire Health Protection Team, either by telephone or by a notification form. If a case involves a food handler this should also prompt urgent notification. The contact number for the West Yorkshire Health Protection Team from 9am to 5pm Monday-Friday is 0113 386 0300. Outside these hours, the Out-of-hours advice service can be contacted on 0114 304 9843.

Back to top

Duration of Treatment

When no causative pathogen is identified empirical treatment should be given for 5 days (Evidence level D).

For specific organisms see table in Directed Antimicrobial Treatment section.

Back to top

Switch to oral agent(s)

If intravenous therapy is required it should be switched to the oral route as soon as the patient fulfils the criteria set out in the LTHT “intravenous to oral switch” guideline. Oral doses are as follows (NB assuming normal renal function):

Back to top

Treatment Failure
In case of treatment failure Discuss with Microbiology or Infectious Diseases.

Back to top

Provenance

Record: 1211
Objective:

Aims

  • To improve the diagnosis and management of acute gastrointestinal infection (including food poisoning) in adults seen in accident and emergency and/or requiring hospital admission.
  • Please note that whilst many of the recommendations in this guideline may be relevant to the management of acute gastroenteritis in the community, it is not the primary aim of this document to advise on that scenario.

Objectives

  • To provide evidence-based recommendations for appropriate diagnosis and investigation of acute gastrointestinal infection (including food poisoning)
  • To provide evidence-based recommendations for appropriate non-antimicrobial management of acute gastrointestinal infection (including food poisoning)
  • To provide evidence-based recommendations for appropriate empirical and directed antimicrobial therapy of acute gastrointestinal infection (including food poisoning) in adults
  • To recommend appropriate dose, route of administration and duration of antimicrobial agents.
  • To advise in the event of antimicrobial allergy.
  • To set-out criteria for referral to specialists.
Clinical condition:

Acute gastroenteritis (including food poisoning) in adult patients

Target patient group: Adults patients seen in Accident and Emergency and all those admitted to hospital
Target professional group(s): Pharmacists
Secondary Care Doctors
Adapted from:

Evidence base

  1. Diarrhoeal disease. Fact sheet 330. WHO; August 2009. Available at: http://www.who.int/mediacentre/factsheets/fs330/en/index.html
  2. Heath Protection Agency. (2011). Campylobacter cases in England and Wales, 1989-2010. Available at http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/Campylobacter/EpidemiologicalData/campyDataEw/. Accessed 01/12/2011.
  3. Health Protection Agency. Salmonella cases by serotype. (2011).
  4. DuPont HL. Travellers' diarrhoea: contemporary approaches to therapy and prevention. Drugs. 2006;66:303-14.
  5. Behravesh C, Jones T, Vugia D et al. Deaths associated with bacterial pathogens transmitted commonly through food: foodborne diseases active surveillance network (FOODNET). J Infect Dis. 2011;204:263-267.
  6. Manatsathit S, Dupont H, Farthing M et al. Guideline for the management of acute diarrhea in adults. J Gastroenterol Hepatol. 2002;17(Suppl):S54-S71.
  7. Guerrant RL et al. Practice guidelines for the management of infectious diarrhea. Clin Infect Dis. 2001;32:331-351.
  8. Farthing M, Feldman R, Finch R et al. The management of infective gastroenteritis in adults. A consensus statement by an expert panel convened by the British Society for the Study of Infection. J Infect. 1996;33:143-152.
  9. Clinical Knowledge Summary. Gastroenteritis. 
  10. Tam C et al. The Second Study of Infectious Intestinal Disease in the Community (IID2 Study). 2011. Available at: http://www.foodbase.org.uk//admintools/reportdocuments/711-1-1206_IID2_Final_Report_September_2011.pdf Accessed 22/11/2011.
  11. Thielman N, Guerrant R. Acute Infectious Diarrhea. New Engl J Med. 2004;350:38-47.
  12. Farthing et al. World Gastroenterology Organisation practice guideline: acute diarrhoea. 2008. 
  13. DuPont HL, Hornick RB. Adverse effect of lomotil therapy in shigellosis. JAMA. 1973;226:1525-8.
  14. Cimolai N, Basalyga S, Mah D, Mirrison B, Carter J. A continuing assessment of risk factors for the development of Escherichia coli 0157:H7-associated haemolytic uremic syndrome. Clin Nephrol. 1994;42:85-9.
  15. Goodman G, Trenholme G, Kaplan R et al. Empiric antimicrobial therapy for domestically acquired acute diarrhea in urban adults. Arch Intern Med. 1990;150:541-6.
  16. Dryden M, Gabb R, Wright . Empirical treatment of severe acute community-acquired gastroenteritis with Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin. Clin Infect Dis. 1996;22:1019-25.
  17. Wistronm J, Jertborn M, Ewall E et al. Empiric treatment of acute diarrheal disease with norfloxacin. A randomized, placebo-controlled study. Swedish study group. Ann Intern Med. 1993;117:202-8.
  18. Sirinavin S, Garner P. Antibiotics for treating salmonella gut infections. Cochrane Database Syst Rev. 2000;(2):CD001167. Available at: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001167/full Accessed 28/11/2011.
  19. Wong C, Jelacic S, Habeeb R, Watkins S, Tarr P. The risk of haemolytic-uremic syndrome after antibiotic threatment of Escherichia coli 0157:H7 infections. N Engl J Med. 2000;342:1930-6.
  20. Zhang X, McDaniel A, Wolf L, Keusch G, Waldor M, Acheson D. Quinolone antibiotics induce shiga-toxin encoding bacteriophages, toxin production, and death in mice. J Infect Dis. 2000;181:664-70.
  21. Safdar N, Said A, Gangnn R, Maki D. Risk of haemolytic uremic syndrome after antibiotic treatment of Escherichia coli O157:H7 enteritis: a meta-analysis. JAMA. 2002;288:996-1001.
  22. Health Protection Agency. (2011). Shigella spp. laboratory reports of faecal isolates reported to the Health Protection Agency Centre for Infections England and Wales, 1992-2010. 
  23. DuPont, H.L. (2010). Chapter 221: Shigella species (bacillary dysentery). In: Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases. 7th edn. Elsevier: Philadelphia.
  24. White AC. (2010). Chapter 283: Cryptosporidium species. In: Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases. 7th edn. Elsevier: Philadelphia.
  25. Public Health England (2013).  UK One Health Report: Joint report on human and animal antibiotic use, sales and resistance.  PHE publications gateway number: 2015160

Evidence levels:
A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.
D. Leeds consensus. (where no national guidance exists or there is wide disagreement with a level C recommendation or where national guidance documents contradict each other)

Back to top

Approved By

Improving Antimicrobial Prescribing Group

Document history

LHP version 1.0

Related information

Not supplied

Equity and Diversity

The Leeds Teaching Hospitals NHS Trust is committed to ensuring that the way that we provide services and the way we recruit and treat staff reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group.